How is a patient with severe hyperglycemia (high blood sugar) treated?

From the Guidelines

Severe hyperglycemia, such as a blood glucose level of 600, requires immediate treatment with intravenous regular insulin and aggressive fluid management to prevent life-threatening complications. The management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis 1.

• The treatment should be individualized based on a careful clinical and laboratory assessment, considering the severity of hyperglycemia, the presence of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state, and the patient's overall health status.
• Intravenous regular insulin is the standard of care for critically ill and mentally obtunded individuals with DKA or hyperosmolar hyperglycemia, and it should be administered at a dose of 0.1 units/kg/hour after an initial bolus of 0.1 units/kg.
• Fluid replacement with normal saline is crucial, often beginning at 15-20 mL/kg/hour for the first hour, then adjusted based on hydration status, and electrolyte replacement, particularly potassium, is necessary as insulin therapy can cause potassium to shift into cells 1.
• The use of bicarbonate in patients with DKA is generally not recommended, as several studies have shown that it makes no difference in the resolution of acidosis or time to discharge 1.
• Once the acute crisis resolves and the patient can eat, transition to subcutaneous insulin occurs, typically with a basal-bolus regimen using long-acting insulin and rapid-acting insulin before meals.
• It is essential to identify and address the underlying cause of hyperglycemia, whether it's undiagnosed diabetes, medication non-adherence, infection, or other stressors, to prevent recurrence and improve patient outcomes 1.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

Treatment for Hyperglycemia:

• The patient should obtain medical assistance immediately.
• The treatment is not explicitly stated in the label, but it can be inferred that insulin administration may be necessary to lower blood glucose levels.
• Patients with severe hyperglycemia or DKA may require intravenous administration of glucose or other treatments at a medical facility 2.

From the Research

Treatment of Severe Hyperglycemia

• Severe hyperglycemia, also known as hyperglycemic hyperosmolar non-ketotic syndrome (HHNS), is a life-threatening complication of uncontrolled diabetes mellitus 3.
• The treatment of HHNS involves restoration of the intravascular volume to assure adequate perfusion of vital organs, correction of deficits of fluid and electrolyte, and hyperglycemia and serum hyperosmolarity 3, 4.
• The principal goal at the outset of therapy must be restoration of the intravascular volume, which can be achieved by administering iso-osomolar isotonic fluid (0.9% saline) until hemodynamic stabilization, followed by 0.45% saline 3, 4.
• Insulin infusion at the rate of 0.1 units/kg/hour is generally recommended, with addition of 5% dextrose in fluids and reduction of insulin infusion once the blood glucose is 250 to 300 mg/dl 3, 4.
• For hyperglycemic patients admitted to an intensive care unit (ICU), the target blood glucose level should be < or =180 mg/dL 5.
• The treatment of diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) is essentially the same, with replacement of the mostly substantial fluid deficit with several liters of a physiological crystalloid solution being the first and most important step 6.

Management of Hyperglycemic Crisis

• Patients with severe hyperglycemia should be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU) 7.
• The management of hyperglycemic crisis involves identification and treatment of precipitating events, correction of insulin deficiency, and reduction of risk of cerebral edema and other complications of therapy 7, 6.
• Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion, with insulin switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range 6.